Essential Plan (with Adult Dental and Vision Options)

EmblemHealth's Essential Plan is a no-deductible HMO plan with a $0 or $20 monthly premium. There are four versions of this plan, and eligibility depends on income and other factors. The Essential Plan is available at any time of year, but only if you enroll on the NY State of Health Marketplace. EmblemHealth EP 3, 4, and Plus plans offer adult vision and dental as well.

Who's eligible: Qualifying adult individuals age 21 or older (there is no family plan) living in one of eight New York counties, including the five New York City boroughs and Nassau, Suffolk, and Westchester counties.

Benefits, premiums (monthly cost), and out-of-pocket costs: All four versions of the Essential Plan include all the essential health benefits, but at different out-of-pocket costs. For benefits, view plan documents below.

Financial assistance: Cost savings are built into these plans through a premium as low as $0 or $20, no deductible, and copays as low as $0. No tax credits or additional financial assistance is offered with this plan.

  • dental
  • vision
  • Generic Drugs
  • telemedicine

Contact Sales
877-411-3625

Benefits Summary

Low premium info Pay $0 or $20 per month for your medical plan, depending on your income and other factors
No deductible info Pay only a copay or nothing at all to use your health benefits
Low or no copays info Pay as little as $0 to see a doctor or get your prescription medicine
Dental and vision coverage Available either at a low added cost or as part of your medical plan, depending on your income and other factors
$0 preventive care info No out-of-pocket costs (no copay, coinsurance, or deductible) for your annual physical, immunizations, and screenings such as a colonoscopy and cervical screening
10 essential health benefits Coverage for all services required under health care reform, such as doctor visits, hospital care, prescription drugs, lab services, maternity care, and mental health and substance use services
$0 telemedicine info  At no extra cost, consult doctors 24/7 about non-urgent medical needs, from a phone, computer, or tablet

 

Three-tier pharmacy benefits info Coverage for generic (i) and brand-name medications, with your share of the costs
Gym reimbursement Over the calendar year, get discounts of up to $400 for you and $200 for your spouse, or get the total cost of both memberships, whichever is less
Wellness programs Get help to eat better, quit smoking, manage a condition, or have a healthy pregnancy
Essential 1 copay (Primary care doctor/specialist/emergency room) $15 / $25 / $75
Essential 2, 3, 4 copay (Primary care doctor/specialist/emergency room) $0 / $0 / $0

 

Find a Doctor

Our Essential Plan provides network-only coverage through EmblemHealth's Enhanced Care Prime network.

 

Our Essential Plan is an HMO plan, which means you must:

  • Seek non-emergency care from doctors, hospitals and facilities in the Enhanced Care Prime network only, in order for your care to be covered
  • Choose a primary care physician (PCP) from the Enhanced Care Prime network. Members can choose or change their PCP by signing in to or registering for a secure online account or by calling 888-447-7703, Monday through Friday, from 8 am to 6 pm
  • Get a referral from your primary care physician in order to see network specialists

  • Benefit Summary - Essential Plan 1

  • Benefit Summary - Essential Plan 1 with dental and vision

  • Benefit Summary - Essential Plan 2

  • Benefit Summary - Essential Plan 2 with dental and vision

  • Benefit Summary - Essential Plan 1 and 2 Native American

  • Benefit Summary - Essential Plan 1 Plus and 2 Plus Native American

  • Benefit Summary - Essential Plan 3

  • Benefit Summary - Essential Plan 4


  • Summary of Benefits and Coverage - Essential Plan 1

  • Summary of Benefits and Coverage - Essential Plan 2

  • Summary of Benefits and Coverage - Essential Plan 2 with dental and vision

  • Summary of Benefits and Coverage - Essential Plan 3

  • Summary of Benefits and Coverage - Essential Plan 4


  • Subscriber Contract - Essential Plan 1

  • Subscriber Contract - Essential Plan 1 with dental and vision

  • Subscriber Contract - Essential Plan 2

  • Subscriber Contract - Essential Plan 2 with dental and vision

  • Subscriber Contract - Essential Plan 3

  • Subscriber Contract - Essential Plan 4

Cost Calculator

Since our Individual/Family and Essential Plans offer network-only coverage, members are responsible for the total cost of non-emergency care they receive outside their plan’s provider network.

 

Use the FAIR Health Calculator* to estimate the cost of non-emergency medical services and procedures by zip code.

 

*FAIR Health, Inc. is an independent nonprofit organization that uses actual provider charges when calculating fees. FAIR Health ensures that its fee information is accurate and complete. Please review the privacy policy and terms and conditions posted on the FAIR Health website.

The Essential Plan is underwritten by HIP Health Plan of New York. Coverage is subject to all terms, conditions, limitations and exclusions set forth in the contract. Refer to HIP policy form number 155-23-EPP1NONAIAN, et al.

  • Enroll on the New York State Marketplace